Do you offer immunosuppression to patients with CTD-ILD with concomitant well controlled HIV?

With the widespread use of highly active antiretroviral therapy (HAART), we have definitely seen an increase in long-term HIV patients who now live long enough and with enough functional immunity to develop CTD-ILD or autoimmune ILD warranting the use of immunosuppression. However, these patients remain relatively rare. As stated in the question, I think it's first important to stress that before treatment of the underlying ILD can be considered, it is important to confirm control of the HIV through persistently normal CD4+ counts and an undetectable viral.

Without getting too granular, it's important to remember that as a general rule of thumb, most antiretroviral medications, especially the NNRTIs and protease inhibitors, are either metabolized by the cytochrome P450 pathway or substrates of the P-gp system. Unfortunately, many immunosuppressive agents are as well, and drug-drug interactions between HAART agents and immunosuppressants (especially the calcineurin inhibitors) remain a concern.

The greatest volume of literature supporting the use of immunosuppression in patients with HIV comes from the transplant population. Therefore, although I'm willing to recommend the use of immunosuppression when these ILD patients arrive in my clinic, I always engage both the ID doctor prescribing the HAART therapy, as well as one of our transplant pharmacists in order to make sure significant dosing adjustments are required. I also tend to monitor safety labs a bit more frequently than I otherwise would.

I agree with @Dr. First Last's response, which is excellent. Primary things to consider would be control of HIV and medication interactions, but I'd also take into account the patient's history of infections, reliability of taking meds and getting monitored, etc.

This is timely since it seems we may see more and more ILDs in HIV patients going forward. Pulmonologists are seeing more ILAs in HIV patients and, though the authors said it's unclear whether we will see these evolve into full-blown ILDs, it's reasonable to assume that is likely.

The little bit of data out there suggest steroids are OK, especially if given over a finite time period. But it's worth noting most HIV-associated ILDs appear to be diseases we often give finite steroid rounds for (e.g., organizing pneumonia, HP), so I am not sure this is the same situation as a CTD-ILD patient who needs indefinite immune suppression with an agent like mycophenolate.

Not a high degree of confidence in this realm, I am sorry.